Rietman Form – Fill Out and Use This PDF

THE CARL AND CAMILLA RIETMAN FOUNDATION SCHOLARSHIP AWARDS

An excellent scholarship opportunity for Coquille students was established in 1997 by Camilla Rietman, widow of Dr. Carl Rietman. A life‑long resident of Coquille, Mrs. Rietman graduated from Coquille High School in 1920. Mrs. Rietman died in 2003 at age 100.

It was Mrs. Rietman’s sincere desire to ensure that as many children as possible have an opportunity to further their education after high school.

The number and dollar amount of scholarships may vary from year to year. In 2019, 61 scholarships of $2,700 each were awarded. These are full scholarships with no repayment required, though they are presented in the hope that each recipient will remember the city of Coquille and its residents in future years in ways each deems appropriate.

Scholarships are not limited to those seeking four year degrees. Students interested in all areas of career training are encouraged to apply. Each Scholarship is for one academic year. Also eligible are home‑school and on‑line graduates and GED holders, all of whom must comply with residence requirements (see “Rietman Scholarship Criteria”).

Scholarship criteria are listed on page four of the application. Please submit the attached application by noon Wednes‑ day, April 15, 2020. Forms are revised periodically, so always obtain current forms from the high school. Application

forms are also available on‑line at www.rietmanscholarship.org. Applicants may use such if they prefer, but must follow all rules for completion and submission in five (5) sets via regular mail or personal delivery.

~ Scholarship Application for April 15, 2020 Submission ~

(please type ‑ handwritten applications will be rejected)

A.PERSONAL DATA

1.Name: _________________________________________________________________________________________________

2.Date of birth:__________________________ Age:_________ Social Security Number (last 4 digits):_______________________

3.Your current residence mailing address: _______________________________________________________________________

(STREET OR P.O. BOX)

City/State: ______________________________________________________________ Zip Code:________________________

Email Address: _______________________________________ Phone:_____________________________________________

4.List the years and grades you have attended in the Coquille School District (years need not be consecutive):

_________________________________________________________ Year of graduation from Coquille High School:_________

5.If you have not attended six full years in the Coquille District, list schools/cities/grades (1‑12) attended elsewhere and why you feel the six year requirement should be waived:

______________________________________________________________________________________________________

______________________________________________________________________________________________________

6.College you plan to attend if you receive this award (name, address, zip, registrar’s phone number):

______________________________________________________________________________________________________

______________________________________________________________________________________________________

________________________________Please enter address we should use to transmit scholarship funds if different from above:

______________________________________________________________________________________________________

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Revised 9/19 for April 15, 2020 submission

D. SUPPLEMENTAL DATA

1.Attach a typewritten summary about yourself and your family, your study habits, community involvement, why you want to continue your schooling, and reasons why you should receive a scholarship. Indicate plans for any employment during college and summer. Limit summary to 200 words. (This is in addition to the B-3 resume).

2.Using the enclosed form, attach reference letters from three adults not related to you. Photocopy both sides of the form as needed.

Attach copies of all three references to the five (5) sets of your application; do not mail reference letters separately. Do not exceed three references, or your application will be rejected. Instruct references to not submit completed form direct to trustees. Assure that each reference receives a copy of the criteria.

3.Transcript of grades: If you are a high school senior, attach a original transcript to your original application and a copy to each of your

other four (4) sets. To other applicants: submit both high school and college transcripts through the last completed term. If your of- ficial college transcript comes to you in a sealed envelope, you may open the envelope to make four copies, but enclose the opened envelope and official transcript with your original application.

E.SECOND (SUBSEQUENT) APPLICATIONS:

If you have submitted an application in a prior year and are now applying for another scholarship, you must attach current references and not utilize copies of prior references.

F.AGREEMENT

1.I have read and accept the criteria and rules of the Rietman Scholarship Fund as outlined herein (see back page of application). I certify that all information I have submitted is true, and I understand that an award may be cancelled if false or inaccurate information

is submitted or if the application fails to comply with criteria and rules. I understand that scholarship funds will be remitted directly to the above college I plan to attend.

2.I authorize the Rietman Foundation to share this information with Scholarship selection committees for purposes of identifying students, determining eligibility and selecting and notifying award recipients.

3.If selected to receive a scholarship, I give permission for a publicity release. I consent to release of scholarship information to my parents/guardian if requested.

4.I agree to pursue my education as described herein for the ensuing academic year and understand that failure to do so will require me to return any remaining unused scholarship to the Foundation. If I do not use funds I will promptly notify the Rietman Foundation at info@rietmanscholarship.org so funds can be made available to other applicants.

5.A copy of this signed application provided to the high school or college shall be deemed my consent for the college to provide the

Foundation any academic or financial information, if I fail to provide such.

6.I understand that if five (5) full sets of my application are not at the front desk of the law office located at 280 N. Collier, Coquille, Oregon

(which faces the court house) by 12 noon on Wednesday, April 15, 2020 my application will be rejected. Applications delivered after 12 noon will be rejected outright. I further understand that if the submitted application fails to comply in any respect with all application rules, it will be rejected without notice to me. Each of the 5 sets must be SECURELY STAPLED - application on top, then other documents. Do not use paper clips. Do not use plastic or other types of covers. SUMMARY: Each of the 5 stapled sets shall include: a) the signed application b) transcripts per D-3 above c) B-3 and D-1 statement d) copies of the 3 reference letters per D-2 and E above e) Also, enclose TWO (2) letter size self-addressed unstamped envelopes.

MAIL OR DELIVER THE ORIGINAL, PLUS 4 FULL COPIES (INCLUDING COPIES OF ALL ATTACHMENTS) PLUS TWO (2) LET- TER SIZE SELF ADDRESSED ENVELOPES, NO STAMPS TO: RIETMAN SCHOLARSHIP FUND TRUSTEE 280 N. COLLIER, COQUILLE, OR 97423. Assure that you have used a current form which states “for April 15, 2020 submission”. (Retain one full copy for your records, as the Foundation keeps no copies after the awards are made). Use mail slot at bottom of front door of the law office (which faces the court house) if office is closed. Do not call for results; notices will be mailed to all applicants. Do not call or contact judges or trustees to dispute or question results. Checks will be mailed to colleges in August.

I acknowledge that the Foundation cannot guarantee applicants will receive a scholarship for which they apply. By signing this form, I agree to hold harmless, defend and indemnify the Rietman Foundation for any acts, failures to act or omissions of the Foundation, its employees, agents or volunteers.

Applicant’s Signature_____________________________________________________________Date _________________________

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